Representatives of a Foreign Interest (RFI)
Statement

A RFI is a citizen or national of the U.S., or an intending
citizen to the U.S., who is acting as a representative of a foreign
interest. If any individual having or requiring a DOE security
clearance is a RFI. A RFI Statement (sample document attached) must
be completed.

A Foreign Interest is any foreign government, agency of a foreign
government, or representative of a foreign government; any form of
business enterprise or legal entity origination, chartered or
incorporated under the laws of any country, other than the U.S. or
its possessions and trust territories, and any person who is no a
citizen at national of the U.S.

Name of the foreign interest:

Address of the foreign interest:

The nature of business of the foreign firm and the
products/services involved. Also indicate if they have any military
application:

Full details of ownership or affiliation with the foreign
interest

The specific relationship between the foreign interest and the
U.S. organization:

Your Job titles and specific duties withthe foreign
interest:

Percentage of time devoted to foreign interest:

Percentage of U.S. organization's revenues and net income derived
from foreign firm during the U.S. organization's most recently
closed accounting year:

Name and address of all U.S. facilities where you hold or are in
process for an access authorization:

The nature of business of all U.S. organizations and the
product/services involved.

Summary of duties with the foreign firm Provide detailed
information, as well as position title:

Have you ever registered as an Agent of a foreign government as
detailed in 18 U.S.C. 219? If so, please provide details:

CERTIFICATION:
I recognize my special responsibility to protect classified
information from disclosure to any unauthorized person, foreign,
or domestic.

TYPE OR PRINTED NAME:________________________________________

FULL NAME:_______________________________ DATE:_______________

Signature____________________________________________________

SOCIAL SECURITY NUMBER:_______________ FACILITY:_______________

Last Modified: February 4, 2008Please forward all questions about this site to:
Barbara Simpson

One of ten national laboratories overseen and primarily funded by the Office of Science of the
U.S. Department of Energy (DOE), Brookhaven National Laboratory conducts research in the
physical, biomedical, and environmental sciences, as well as in energy technologies and
national security. Brookhaven Lab also builds and operates major scientific facilities
available to university, industry and government researchers. Brookhaven is operated and
managed for DOE's Office of Science by Brookhaven Science Associates, a limited-liability
company founded by the Research Foundation for the State University of New York on behalf
of Stony Brook University, the largest academic user of Laboratory facilities, and Battelle,
a nonprofit, applied science and technology organization.